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CC BY-NC-ND 4.0 · Indian J Med Paediatr Oncol 2021; 42(05): 406-414
DOI: 10.1055/s-0041-1739345
Review Article

Controversies in Mediastinal Staging for Nonsmall Cell Lung Cancer

Apurva Ashok
1   Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
,
Sabita S. Jiwnani
1   Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
,
George Karimundackal
1   Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
,
Maheema Bhaskar
2   Department of Pulmonology, Tata Memorial Hospital, Mumbai, Maharashtra, India
,
Nitin S. Shetty
3   Division of Interventional Radiology, Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
,
Virendra Kumar Tiwari
1   Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
,
Devayani M. Niyogi
1   Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
,
C. S. Pramesh
1   Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Abstract

Mediastinal lymph nodal involvement in nonsmall cell lung cancer plays a crucial role in deciding treatment strategy. Survival falls markedly with increasing involvement of mediastinal nodal stations. Hence, accurate staging of the mediastinum with lowest morbidity is of utmost importance. A wide array of invasive and noninvasive modalities that complement each other in assessing the nodes are available at our disposal. Guidelines recommend noninvasive imaging as the initial step in the staging algorithm for all tumors, followed by invasive staging. No single modality has proven to be the ideal method to stage the mediastinum when used alone. In the present decade, minimally invasive endobronchial ultrasound (EBUS) has challenged the position of surgical mediastinoscopy, which has been the gold standard, historically. However, a negative EBUS needs to be confirmed by surgical mediastinoscopy. Video-assisted mediastinoscopic lymphadenectomy has also come to the forefront in last two decades and has shown exceptional results, when performed in experienced centers. This review details the various modalities of mediastinal staging and the controversies surrounding the optimal method of staging, restaging after neoadjuvant therapy, and the most cost-effective strategy.

Keywords

mediastinal staging - endobronchial ultrasound - mediastinoscopy - VAMLA - nonsmall cell lung cancer


Publication History

Article published online:
24 December 2021

© 2021. Indian Society of Medical and Paediatric Oncology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68 (06) 394-424
    CrossrefPubMedGoogle Scholar
  • 2 Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143 (Suppl. 05) e278S-e313S
    CrossrefPubMedGoogle Scholar
  • 3 Osaki T, Nagashima A, Yoshimatsu T, Tashima Y, Yasumoto K. Survival and characteristics of lymph node involvement in patients with N1 non-small cell lung cancer. Lung Cancer 2004; 43 (02) 151-157
    CrossrefPubMedGoogle Scholar
  • 4 Asamura H, Chansky K, Crowley J. et al. International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee, Advisory Board Members, and Participating Institutions. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: proposals for the revision of the N descriptors in the forthcoming 8th edition of the TNM classification for lung cancer. J Thorac Oncol 2015; 10 (12) 1675-1684
    CrossrefPubMedGoogle Scholar
  • 5 Silvestri GA, Gonzalez AV, Jantz MA. et al. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143 (05) (Suppl) e211S-e250S
    CrossrefPubMedGoogle Scholar
  • 6 Gould MK, Kuschner WG, Rydzak CE. et al. Test performance of positron emission tomography and computed tomography for mediastinal staging in patients with non-small-cell lung cancer: a meta-analysis. Ann Intern Med 2003; 139 (11) 879-892
    CrossrefPubMedGoogle Scholar
  • 7 Schmidt-Hansen M, Baldwin DR, Hasler E, Zamora J, Abraira V, Roqué I Figuls M. PET-CT for assessing mediastinal lymph node involvement in patients with suspected resectable non-small cell lung cancer. Cochrane Database Syst Rev 2014; 201 (11) CD009519
    Google Scholar
  • 8 Kozower BD, Meyers BF, Reed CE, Jones DR, Decker PA, Putnam Jr JB. Does positron emission tomography prevent nontherapeutic pulmonary resections for clinical stage IA lung cancer?. Ann Thorac Surg 2008; 85 (04) 1166-1169 discussion 1169–1170
    CrossrefPubMedGoogle Scholar
  • 9 Farrell MA, McAdams HP, Herndon JE. Patz EF Jr. Non-small cell lung cancer: FDG PET for nodal staging in patients with stage I disease. Radiology 2000; 215 (03) 886-890
    CrossrefPubMedGoogle Scholar
  • 10 Purandare NC, Pramesh CS, Agarwal JP. et al. Solitary pulmonary nodule evaluation in regions endemic for infectious diseases: do regional variations impact the effectiveness of fluorodeoxyglucose positron emission tomography/computed tomography. Indian J Cancer 2017; 54 (01) 271-275
    CrossrefPubMedGoogle Scholar
  • 11 Detterbeck FC, Falen S, Rivera MP, Halle JS, Socinski MA. Seeking a home for a PET, part 2: defining the appropriate place for positron emission tomography imaging in the staging of patients with suspected lung cancer. Chest 2004; 125 (06) 2300-2308
    CrossrefPubMedGoogle Scholar
  • 12 Detterbeck FC, Falen S, Rivera MP, Halle JS, Socinski MA. Seeking a home for a PET, part 1: defining the appropriate place for positron emission tomography imaging in the diagnosis of pulmonary nodules or masses. Chest 2004; 125 (06) 2294-2299
    CrossrefPubMedGoogle Scholar
  • 13 Wang J, Welch K, Wang L, Kong FM. Negative predictive value of positron emission tomography and computed tomography for stage T1-2N0 non-small-cell lung cancer: a meta-analysis. Clin Lung Cancer 2012; 13 (02) 81-89
    CrossrefPubMedGoogle Scholar
  • 14 The American Thoracic Society and The European Respiratory Society. Pretreatment evaluation of non-small-cell lung cancer. Am J Respir Crit Care Med 1997; 156 (01) 320-332
    CrossrefPubMedGoogle Scholar
  • 15 Gómez-Caro A, Boada M, Cabañas M. et al. False-negative rate after positron emission tomography/computer tomography scan for mediastinal staging in cI stage non-small-cell lung cancer. Eur J Cardiothorac Surg 2012; 42 (01) 93-100 discussion 100
    CrossrefPubMedGoogle Scholar
  • 16 Lee PC, Port JL, Korst RJ, Liss Y, Meherally DN, Altorki NK. Risk factors for occult mediastinal metastases in clinical stage I non-small cell lung cancer. Ann Thorac Surg 2007; 84 (01) 177-181
    CrossrefPubMedGoogle Scholar
  • 17 Hishida T, Yoshida J, Nishimura M, Nishiwaki Y, Nagai K. Problems in the current diagnostic standards of clinical N1 non-small cell lung cancer. Thorax 2008; 63 (06) 526-531
    CrossrefPubMedGoogle Scholar
  • 18 De Leyn P, Dooms C, Kuzdzal J. et al. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg 2014; 45 (05) 787-798
    CrossrefPubMedGoogle Scholar
  • 19 Webb WR, Gatsonis C, Zerhouni EA. et al. CT and MR imaging in staging non-small cell bronchogenic carcinoma: report of the radiologic diagnostic oncology group. Radiology 1991; 178 (03) 705-713
    CrossrefPubMedGoogle Scholar
  • 20 Wu LM, Xu JR, Gu HY. et al. Preoperative mediastinal and hilar nodal staging with diffusion-weighted magnetic resonance imaging and fluorodeoxyglucose positron emission tomography/computed tomography in patients with non-small-cell lung cancer: which is better?. J Surg Res 2012; 178 (01) 304-314
    CrossrefPubMedGoogle Scholar
  • 21 Rusch VW, Asamura H, Watanabe H, Giroux DJ, Rami-Porta R, Goldstraw P. Members of IASLC Staging Committee. The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol 2009; 4 (05) 568-577
    CrossrefPubMedGoogle Scholar
  • 22 Lee HS, Lee GK, Lee HS. et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration in mediastinal staging of non-small cell lung cancer: how many aspirations per target lymph node station?. Chest 2008; 134 (02) 368-374
    CrossrefPubMedGoogle Scholar
  • 23 Block MI. Endobronchial ultrasound for lung cancer staging: how many stations should be sampled?. Ann Thorac Surg 2010; 89 (05) 1582-1587
    CrossrefPubMedGoogle Scholar
  • 24 Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer 2009; 45 (08) 1389-1396
    CrossrefPubMedGoogle Scholar
  • 25 von Bartheld MB, Versteegh MI, Braun J, Willems LN, Rabe KF, Annema JT. Transesophageal ultrasound-guided fine-needle aspiration for the mediastinal restaging of non-small cell lung cancer. J Thorac Oncol 2011; 6 (09) 1510-1515
    CrossrefPubMedGoogle Scholar
  • 26 Uemura S, Yasuda I, Kato T. et al. Preoperative routine evaluation of bilateral adrenal glands by endoscopic ultrasound and fine-needle aspiration in patients with potentially resectable lung cancer. Endoscopy 2013; 45 (03) 195-201
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Nguyen P, Feng JC, Chang KJ. Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (FNA) of liver lesions. Gastrointest Endosc 1999; 50 (03) 357-361
    CrossrefPubMedGoogle Scholar
  • 28 Hwangbo B, Lee GK, Lee HS. et al. Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest 2010; 138 (04) 795-802
    CrossrefPubMedGoogle Scholar
  • 29 Herth FJ, Krasnik M, Kahn N, Eberhardt R, Ernst A. Combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes through a single bronchoscope in 150 patients with suspected lung cancer. Chest 2010; 138 (04) 790-794
    CrossrefPubMedGoogle Scholar
  • 30 Crombag LMM, Dooms C, Stigt JA. et al. Systematic and combined endosonographic staging of lung cancer (SCORE study. Eur Respir J 2019; 53 (02) 1800800
    CrossrefPubMedGoogle Scholar
  • 31 Dong X, Qiu X, Liu Q, Jia J. Endobronchial ultrasound-guided transbronchial needle aspiration in the mediastinal staging of non-small cell lung cancer: a meta-analysis. Ann Thorac Surg 2013; 96 (04) 1502-1507
    CrossrefPubMedGoogle Scholar
  • 32 Ost DE, Ernst A, Lei X. et al. AQuIRE Bronchoscopy Registry. Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE Bronchoscopy Registry. Chest 2011; 140 (06) 1557-1566
    CrossrefPubMedGoogle Scholar
  • 33 Oki M, Saka H, Kitagawa C. et al. Rapid on-site cytologic evaluation during endobronchial ultrasound-guided transbronchial needle aspiration for diagnosing lung cancer: a randomized study. Respiration 2013; 85 (06) 486-492
    CrossrefPubMedGoogle Scholar
  • 34 Yarmus LB, Akulian J, Lechtzin N. et al. American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation (AQuIRE) Participants. Comparison of 21-gauge and 22-gauge aspiration needle in endobronchial ultrasound-guided transbronchial needle aspiration: results of the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation Registry. Chest 2013; 143 (04) 1036-1043
    CrossrefPubMedGoogle Scholar
  • 35 Wallace MB, Pascual JM, Raimondo M. et al. Minimally invasive endoscopic staging of suspected lung cancer. JAMA 2008; 299 (05) 540-546
    CrossrefPubMedGoogle Scholar
  • 36 Szlubowski A, Zieliński M, Soja J. et al. A combined approach of endobronchial and endoscopic ultrasound-guided needle aspiration in the radiologically normal mediastinum in non-small-cell lung cancer staging–a prospective trial. Eur J Cardiothorac Surg 2010; 37 (05) 1175-1179
    CrossrefPubMedGoogle Scholar
  • 37 Kang HJ, Hwangbo B, Lee GK. et al. EBUS-centred versus EUS-centred mediastinal staging in lung cancer: a randomised controlled trial. Thorax 2014; 69 (03) 261-268
    CrossrefPubMedGoogle Scholar
  • 38 Defranchi SA, Edell ES, Daniels CE. et al. Mediastinoscopy in patients with lung cancer and negative endobronchial ultrasound guided needle aspiration. Ann Thorac Surg 2010; 90 (06) 1753-1757
    CrossrefPubMedGoogle Scholar
  • 39 Yasufuku K, Pierre A, Darling G. et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg 2011; 142 (06) 1393-400.e1
    CrossrefPubMedGoogle Scholar
  • 40 Sehgal IS, Dhooria S, Aggarwal AN, Behera D, Agarwal R. Endosonography versus mediastinoscopy in mediastinal staging of lung cancer: systematic review and meta-analysis. Ann Thorac Surg 2016; 102 (05) 1747-1755
    CrossrefPubMedGoogle Scholar
  • 41 Annema JT, van Meerbeeck JP, Rintoul RC. et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA 2010; 304 (20) 2245-2252
    CrossrefPubMedGoogle Scholar
  • 42 Adams K, Shah PL, Edmonds L, Lim E. Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: systematic review and meta-analysis. Thorax 2009; 64 (09) 757-762
    CrossrefPubMedGoogle Scholar
  • 43 Chandra S, Nehra M, Agarwal D, Mohan A. Diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle biopsy in mediastinal lymphadenopathy: a systematic review and meta-analysis. Respir Care 2012; 57 (03) 384-391
    CrossrefPubMedGoogle Scholar
  • 44 Zhang R, Ying K, Shi L, Zhang L, Zhou L. Combined endobronchial and endoscopic ultrasound-guided fine needle aspiration for mediastinal lymph node staging of lung cancer: a meta-analysis. Eur J Cancer 2013; 49 (08) 1860-1867
    CrossrefPubMedGoogle Scholar
  • 45 Bousema JE, van Dorp M, Noyez VJJM, Dijkgraaf MGW, Annema JT, van den Broek FJC. Unforeseen N2 disease after negative endosonography findings with or without confirmatory mediastinoscopy in resectable non-small cell lung cancer: a systematic review and meta-analysis. J Thorac Oncol 2019; 14 (06) 979-992
    CrossrefPubMedGoogle Scholar
  • 46 Bousema JE, Dijkgraaf MGW, Papen-Botterhuis NE. MEDIASTrial study group. et al. MEDIASTinal staging of non-small cell lung cancer by endobronchial and endoscopic ultrasonography with or without additional surgical mediastinoscopy (MEDIASTrial): study protocol of a multicenter randomised controlled trial. BMC Surg 2018; 18 (01) 27
    CrossrefPubMedGoogle Scholar
  • 47 Lemaire A, Nikolic I, Petersen T. et al. Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate. Ann Thorac Surg 2006; 82 (04) 1185-1189 discussion 1189–1190
    CrossrefPubMedGoogle Scholar
  • 48 Zakkar M, Tan C, Hunt I. Is video mediastinoscopy a safer and more effective procedure than conventional mediastinoscopy?. Interact Cardiovasc Thorac Surg 2012; 14 (01) 81-84
    CrossrefPubMedGoogle Scholar
  • 49 Cho JH, Kim J, Kim K, Choi YS, Kim HK, Shim YM. A comparative analysis of video-assisted mediastinoscopy and conventional mediastinoscopy. Ann Thorac Surg 2011; 92 (03) 1007-1011
    CrossrefPubMedGoogle Scholar
  • 50 Vilmann P, Frost Clementsen P, Colella S. et al. Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg 2015; 48 (01) 1-15
    CrossrefPubMedGoogle Scholar
  • 51 Darling GE. Current status of mediastinal lymph node dissection versus sampling in non-small cell lung cancer. Thorac Surg Clin 2013; 23 (03) 349-356
    CrossrefPubMedGoogle Scholar
  • 52 Mokhles S, Macbeth F, Treasure T. et al. Systematic lymphadenectomy versus sampling of ipsilateral mediastinal lymph-nodes during lobectomy for non-small-cell lung cancer: a systematic review of randomized trials and a meta-analysis. Eur J Cardiothorac Surg 2017; 51 (06) 1149-1156
    CrossrefPubMedGoogle Scholar
  • 53 Cerfolio RJ, Bryant AS, Eloubeidi MA. Accessing the aortopulmonary window (#5) and the paraaortic (#6) lymph nodes in patients with non-small cell lung cancer. Ann Thorac Surg 2007; 84 (03) 940-945
    CrossrefPubMedGoogle Scholar
  • 54 Sebastián-Quetglás F, Molins L, Baldó X, Buitrago J, Vidal G. Spanish Video-assisted Thoracic Surgery Study Group. Clinical value of video-assisted thoracoscopy for preoperative staging of non-small cell lung cancer. A prospective study of 105 patients. Lung Cancer 2003; 42 (03) 297-301
    CrossrefPubMedGoogle Scholar
  • 55 Osarogiagbon RU, Lee YS, Faris NR, Ray MA, Ojeabulu PO, Smeltzer MP. Invasive mediastinal staging for resected non-small cell lung cancer in a population-based cohort. J Thorac Cardiovasc Surg 2019; 158 (04) 1220-1229.e2
    CrossrefPubMedGoogle Scholar
  • 56 Obiols C, Call S, Rami-Porta R. et al. Extended cervical mediastinoscopy: mature results of a clinical protocol for staging bronchogenic carcinoma of the left lung. Eur J Cardiothorac Surg 2012; 41 (05) 1043-1046
    CrossrefPubMedGoogle Scholar
  • 57 Hürtgen M, Friedel G, Toomes H, Fritz P. Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA)–technique and first results. Eur J Cardiothorac Surg 2002; 21 (02) 348-351
    CrossrefPubMedGoogle Scholar
  • 58 Witte B, Wolf M, Huertgen M, Toomes H. Video-assisted mediastinoscopic surgery: clinical feasibility and accuracy of mediastinal lymph node staging. Ann Thorac Surg 2006; 82 (05) 1821-1827
    CrossrefPubMedGoogle Scholar
  • 59 Sayar A, Çitak N, Metin M. et al. Comparison of video-assisted mediastinoscopy and video-assisted mediastinoscopic lymphadenectomy for lung cancer. Gen Thorac Cardiovasc Surg 2011; 59 (12) 793-798
    CrossrefPubMedGoogle Scholar
  • 60 Decaluwé H, Dooms C, D’Journo XB. et al. Mediastinal staging by videomediastinoscopy in clinical N1 non-small cell lung cancer: a prospective multicentre study. Eur Respir J 2017; 50 (06) 1701493
    CrossrefPubMedGoogle Scholar
  • 61 Kuzdzał J, Zieliński M, Papla B. et al. The transcervical extended mediastinal lymphadenectomy versus cervical mediastinoscopy in non-small cell lung cancer staging. Eur J Cardiothorac Surg 2007; 31 (01) 88-94
    CrossrefPubMedGoogle Scholar
  • 62 Zielinski M, Szlubowski A, Kołodziej M. et al. Comparison of endobronchial ultrasound and/or endoesophageal ultrasound with transcervical extended mediastinal lymphadenectomy for staging and restaging of non-small-cell lung cancer. J Thorac Oncol 2013; 8 (05) 630-636
    CrossrefPubMedGoogle Scholar
  • 63 Cerfolio RJ, Bryant AS, Ojha B. Restaging patients with N2 (stage IIIa) non-small cell lung cancer after neoadjuvant chemoradiotherapy: a prospective study. J Thorac Cardiovasc Surg 2006; 131 (06) 1229-1235
    CrossrefPubMedGoogle Scholar
  • 64 Herth FJ, Annema JT, Eberhardt R. et al. Endobronchial ultrasound with transbronchial needle aspiration for restaging the mediastinum in lung cancer. J Clin Oncol 2008; 26 (20) 3346-3350
    CrossrefPubMedGoogle Scholar
  • 65 Stigt JA, Oostdijk AH, Timmer PR, Shahin GM, Boers JE, Groen HJ. Comparison of EUS-guided fine needle aspiration and integrated PET-CT in restaging after treatment for locally advanced non-small cell lung cancer. Lung Cancer 2009; 66 (02) 198-204
    CrossrefPubMedGoogle Scholar
  • 66 Stamatis G, Fechner S, Hillejan L, Hinterthaner M, Krbek T. Repeat mediastinoscopy as a restaging procedure. Pneumologie 2005; 59 (12) 862-866
    Article in Thieme ConnectPubMedGoogle Scholar
  • 67 Lardinois D, Schallberger A, Betticher D, Ris HB. Postinduction video-mediastinoscopy is as accurate and safe as video-mediastinoscopy in patients without pretreatment for potentially operable non-small cell lung cancer. Ann Thorac Surg 2003; 75 (04) 1102-1106
    CrossrefPubMedGoogle Scholar
  • 68 Yendamuri S, Battoo A, Dy G. et al. Transcervical extended Mediastinal lymphadenectomy: experience from a north American Cancer Center. Ann Thorac Surg 2017; 104 (05) 1644-1649
    CrossrefPubMedGoogle Scholar
  • 69 Czarnecka-Kujawa K, Rochau U, Siebert U. et al. Cost-effectiveness of mediastinal lymph node staging in non-small cell lung cancer. J Thorac Cardiovasc Surg 2017; 153 (06) 1567-1578
    CrossrefPubMedGoogle Scholar
  • 70 Steinfort DP, Liew D, Conron M, Hutchinson AF, Irving LB. Cost-benefit of minimally invasive staging of non-small cell lung cancer: a decision tree sensitivity analysis. J Thorac Oncol 2010; 5 (10) 1564-1570
    CrossrefPubMedGoogle Scholar
  • 71 Steinhauser Motta JP, Steffen RE, Samary Lobato C, Souza Mendonça V, Lapa E Silva JR. Endobronchial ultrasound-guided transbronchial needle aspiration versus mediastinoscopy for mediastinal staging of lung cancer: a systematic review of economic evaluation studies. PLoS One 2020; 15 (06) e0235479
    CrossrefPubMedGoogle Scholar